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Ronningstam E, Weinberg I. Narcissistic Personality Disorder: Patterns, Processes, and Indicators of Change in Long-Term Psychotherapy. J Pers Disord 2023; 37:337-357. [PMID: 37367820 DOI: 10.1521/pedi.2023.37.3.337] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
Change in treatment of narcissistic personality disorder (NPD) has been considered difficult to attain. Aspects of narcissistic pathology, including interpersonal enhancement, avoidance, aggressivity, and control, have contributed to challenges in forming a therapeutic alliance and pursuing treatment towards attainable goals for change and remission. This study, based on a qualitative review of therapists' case reports of individual psychotherapy with eight patients diagnosed with NPD, is the first to identify and explore patterns, processes, and indicators of change in pathological narcissism. All patients showed significant improvement in personality and life functioning, including engagement in work or education and long-term close relationships, with remission of the NPD diagnosis. The process of change was gradual, with some noticeable changes occurring in specific life contexts. Additional factors indicating and contributing to change included patients' motivation and commitment to psychotherapy, reflective ability, emotion regulation, sense of agency, and interpersonal and social engagement.
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Affiliation(s)
- Elsa Ronningstam
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Igor Weinberg
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
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Di Sarno M, Frisina S, Madeddu F, Di Pierro R. Interpersonal perceptions in treatment sessions: Pathological narcissism predicts self-rater discrepancies. J Clin Psychol 2023; 79:1002-1020. [PMID: 36322920 DOI: 10.1002/jclp.23454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 10/12/2022] [Accepted: 10/19/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Evidence suggests that pathological narcissism impacts psychotherapy process and outcome. This study investigates whether traits of pathological narcissism account for distinctiveness (construal) of patients' interpersonal perceptions in treatment settings. METHODS Patients enrolled in psychological/psychotherapeutic treatment (N = 150) described a segment of a session in a written format and subsequently assessed both self- and clinician's behavior on the dimensions of dominance and hostility (patient-reported ratings), along with their pathological narcissistic traits. Three independent raters also assessed interpersonal behaviors (observer-reported ratings) based on the written session descriptions. Indices of construal were defined by the residuals of self-reported (net of observer-reported) ratings and were regressed onto pathological narcissistic traits. RESULTS No association emerged between pathological narcissism and construal in patients' perceptions of their clinicians. However, grandiose traits of pathological narcissism were related to distinctively perceiving oneself as more dominant, while vulnerable traits were related to distinctively perceiving oneself as more hostile. The former association (but not the latter) also held after incorporating additional observer ratings to investigate the robustness of the results. CONCLUSION Findings are discussed in light of treatment-related self-enhancement and self-concealment processes.
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Affiliation(s)
- Marco Di Sarno
- Department of Psychology, University of Milano-Bicocca, Milano, Italy.,Personality Disorders Lab (PDlab), Parma-Milano, Milano, Italy
| | - Simone Frisina
- Department of Psychology, University of Milano-Bicocca, Milano, Italy
| | - Fabio Madeddu
- Department of Psychology, University of Milano-Bicocca, Milano, Italy.,Personality Disorders Lab (PDlab), Parma-Milano, Milano, Italy
| | - Rossella Di Pierro
- Department of Psychology, University of Milano-Bicocca, Milano, Italy.,Personality Disorders Lab (PDlab), Parma-Milano, Milano, Italy
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Babl A, Gómez Penedo JM, Berger T, Schneider N, Sachse R, Kramer U. Change processes in psychotherapy for patients presenting with histrionic personality disorder. Clin Psychol Psychother 2023; 30:64-72. [PMID: 35776063 PMCID: PMC10084191 DOI: 10.1002/cpp.2769] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 06/13/2022] [Accepted: 06/27/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Histrionic personality disorder (HPD) with a lifetime prevalence rate of 1.8% is an under-researched psychiatric diagnosis. The present study therefore aimed to investigate both the processes and outcomes of psychotherapy for HPD in a non-controlled study. METHODS A total of 159 patients diagnosed with HPD were recruited and received clarification-oriented psychotherapy. Sessions 15, 20, and 25 were video-recorded and analysed using the Process-Content-Relationship Scale. Therapy outcome was assessed with symptom measures at intake and discharge. Hierarchical linear modelling was applied to estimate the changes in the psychotherapeutic outcome and associations with patient and therapist process developments. RESULTS Improvements in relationship processes of patients and therapists were systematically related to outcome while only partial relationships were found on the levels of process and content. CONCLUSION The present study represents the first systematic insight into core changes in patients with HPD undergoing psychotherapy.
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Affiliation(s)
- Anna Babl
- Adelphi University, Garden City, New York, USA.,University of Bern, Bern, Switzerland
| | | | | | | | - Rainer Sachse
- Institute for Psychological Psychotherapy, University of Bochum, Bochum, Germany
| | - Ueli Kramer
- Lausanne University Hospital, Lausanne, Switzerland.,University of Windsor, Windsor, Ontario, Canada
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Babl A, Berger T, Eubanks CF, Gómez Penedo JM, Caspar F, Sachse R, Kramer U. Addressing interpersonal patterns in patients with personality disorders partially explains psychotherapy outcome via changes in interaction patterns: A mediation analysis. Psychother Res 2022; 32:984-994. [PMID: 35226564 DOI: 10.1080/10503307.2022.2036383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE Many patients with personality disorders (PDs) present with problematic interaction patterns. These may also manifest in the therapeutic relationship. For successful treatment, therapists must therefore find effective ways to address such problematic interaction patterns. METHODS A total of 382 patients with PDs were recruited within a naturalistic setting and received integrative cognitive-behavioral therapy (CBT). Two subscales of the observer-rated Process-Content-Relationship Scale were applied to sessions 15, 20, and 25 of treatment: one on patient interaction patterns and the other on therapist addressing these. Symptom severity was assessed at intake and discharge. Mediation analysis was applied. RESULTS We found significant main effects of (1) therapists' addressing problematic interaction patterns in session 15 on patients' changes in such patterns from session 15 to 25 and (2) patients' changes in problematic interaction patterns on symptom severity at treatment termination. Further, the effect of therapists' addressing problematic interaction patterns on outcome was mediated by changes in patients' interaction patterns. CONCLUSION The results indicate that therapists' addressing of PD patients' problematic interaction patterns may be particularly important to improve such patterns and thereby treatment outcome. Future research should identify in which patients the mechanism of addressing interaction patterns works best.
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Affiliation(s)
- Anna Babl
- Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland
| | - Thomas Berger
- Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland
| | | | | | - Franz Caspar
- Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland
| | - Rainer Sachse
- Department of Clinical Psychology and Psychotherapy, University of Bochum, Bochum, Germany
| | - Ueli Kramer
- Department of Psychiatry, University of Lausanne, Lausanne, Switzerland
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Kealy D, Woolgar S, Hewitt JMA. Investigating pathological narcissism and loneliness, and the link with life satisfaction. Scand J Psychol 2021; 63:32-38. [PMID: 34524693 DOI: 10.1111/sjop.12773] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 05/29/2021] [Accepted: 08/02/2021] [Indexed: 11/30/2022]
Abstract
Loneliness is a significant health concern that may be influenced by dispositional features. Pathological narcissism may elevate loneliness through aversive interpersonal behaviors and negative social appraisals. The present study examined two dimensions of pathological narcissism, along with five-factor personality traits, in relation to loneliness among 120 young adults. Loneliness was also examined as a mediator between pathological narcissism and satisfaction with life. Narcissistic grandiosity and narcissistic vulnerability were both significantly associated with loneliness. Multiple regression analysis, including five-factor traits, revealed narcissistic vulnerability to be uniquely associated with loneliness, along with neuroticism. Mediation analysis also found an indirect effect of narcissistic vulnerability on reduced satisfaction with life, through loneliness as a mediator. These preliminary findings point to future research needs and potential clinical consideration of narcissistic vulnerability as a dispositional risk factor for loneliness.
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Affiliation(s)
- David Kealy
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | - Sarah Woolgar
- Department of Psychiatry, University of British Columbia, Vancouver, Canada.,Counselling Psychology Program, University of British Columbia, Vancouver, Canada
| | - Jackson M A Hewitt
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
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Schalkwijk F, Luyten P, Ingenhoven T, Dekker J. Narcissistic Personality Disorder: Are Psychodynamic Theories and the Alternative DSM-5 Model for Personality Disorders Finally Going to Meet? Front Psychol 2021; 12:676733. [PMID: 34335390 PMCID: PMC8321510 DOI: 10.3389/fpsyg.2021.676733] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 05/25/2021] [Indexed: 11/25/2022] Open
Abstract
Narcissistic Personality Disorder is the new borderline personality disorder of our current era. There have been recent developments on narcissism that are certainly worthwhile examining. Firstly, relational and intersubjective psychoanalysts have been rethinking the underlying concepts of narcissism, focusing on the development of self and relations to others. Secondly, in the DSM-5, the Alternative DSM-5 Model for Personality Disorders (AMPD) was presented for a dimensional evaluation of the severity of personality disorder pathology. The combined dimensional and trait conceptualization of NPD opened the door to new integrated diagnostic perspectives, including both internal and interpersonal functioning. Finally, Pincus and Lukowitsky encourage clinicians to use a hierarchical model of pathological narcissism, as it opens up opportunities for shared points of interest in empirical research from different scholarly perspectives. As for most non-psychodynamic clinicians and researchers the DSM-5 clearly bears dominant weight in their work, we will take the AMPD model for NPD as our point of reference. We will discuss the narcissist's unique pattern of self-impairments in identity and self-direction, and of interpersonal disfunctioning (evaluated by assessing empathy and intimacy). Subsequently, we will examine how contemporary psychodynamic theories and the hierarchical model of Pincus and Lukowitsky additionally inform or contradict the AMPD. For us, one of the big advantages of the AMPD is the use of structured clinical evaluations of disturbances of the self and interpersonal functioning and the dimensional evaluation of severity. As psychodynamically oriented therapists, we are enthusiastic about the opportunities for inclusion of psychodynamic concepts, but we also discuss a number of sticking points.
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Affiliation(s)
- Frans Schalkwijk
- Department of Forensic Special Education, University of Amsterdam, Amsterdam, Netherlands
| | - Patrick Luyten
- Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom.,KU Leuven, Leuven, Belgium
| | | | - Jack Dekker
- Arkin, Amsterdam, Netherlands.,Department of Clinical Psychology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
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Kramer U, Beuchat H, Grandjean L, Pascual-Leone A. How Personality Disorders Change in Psychotherapy: a Concise Review of Process. Curr Psychiatry Rep 2020; 22:41. [PMID: 32519017 DOI: 10.1007/s11920-020-01162-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
PURPOSE OF REVIEW The present review summarizes the current state of the art in psychotherapy processes during treatments for clients with personality disorders. We outline some methodological challenges in the discipline of process research, give a brief historical account on process research, and then focus on specific processes studied from an empirical perspective. RECENT FINDINGS The current review acknowledges the centrality of the therapeutic relationship, in particular the therapeutic alliance, therapist empathy, and responsiveness in explaining outcome across treatment modalities for personality disorders. The review describes evidence from three overall and overlapping lines of inquiry that have garnered scientific interest in the past years. For emotional change (regulation, awareness, and transformation), socio-cognitive change (mentalizing, meta-cognition, and interpersonal patterns), and increase in insight and change in defense mechanisms, evidence is moderate to strong for these processes to contribute to healthy change in treatments for personality disorders, in particular borderline personality disorder. Avenues of future studies are outlined.
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Affiliation(s)
- Ueli Kramer
- Department of Psychiatry-CHUV, Institute of Psychotherapy, University of Lausanne, Place Chauderon 18, CH-1003, Lausanne, Switzerland. .,General Psychiatry Service, Department of Psychiatry-CHUV, University of Lausanne, Lausanne, Switzerland. .,Department of Psychology, University of Windsor, Windsor, Canada.
| | - Hélène Beuchat
- Department of Psychiatry-CHUV, Institute of Psychotherapy, University of Lausanne, Place Chauderon 18, CH-1003, Lausanne, Switzerland
| | - Loris Grandjean
- Department of Psychiatry-CHUV, Institute of Psychotherapy, University of Lausanne, Place Chauderon 18, CH-1003, Lausanne, Switzerland
| | - Antonio Pascual-Leone
- Department of Psychiatry-CHUV, Institute of Psychotherapy, University of Lausanne, Place Chauderon 18, CH-1003, Lausanne, Switzerland.,Department of Psychology, University of Windsor, Windsor, Canada
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